How to Reduce Head CT Orders in Children with Hydrocephalus Using the Lean Six Sigma Methodology: Experience at a Major Quaternary Care Academic Children's Center.

BACKGROUND AND PURPOSE: Lean Six Sigma methodology is increasingly used to drive improvement in patient safety, quality of care, and cost-effectiveness throughout the US health care delivery system. To demonstrate our value as specialists, radiologists can combine lean methodologies along with imaging expertise to optimize imaging elements-of-care pathways. In this article, we describe a Lean Six Sigma project with the goal of reducing the relative use of pediatric head CTs in our population of patients with hydrocephalus by 50% within 6 months. MATERIALS AND METHODS: We applied a Lean Six Sigma methodology using a multidisciplinary team at a quaternary care academic children's center. The existing baseline imaging practice for hydrocephalus was outlined in a Kaizen session, and potential interventions were discussed. An improved radiation-free workflow with ultrafast MR imaging was created. Baseline data were collected for 3 months by using the departmental radiology information system. Data collection continued postintervention and during the control phase (each for 3 months). The percentage of neuroimaging per technique (head CT, head ultrasound, ultrafast brain MR imaging, and routine brain MR imaging) was recorded during each phase. RESULTS: The improved workflow resulted in a 75% relative reduction in the percentage of hydrocephalus imaging performed by CT between the pre- and postintervention/control phases (Z-test, P = .0001). CONCLUSIONS: Our lean interventions in the pediatric hydrocephalus care pathway resulted in a significant reduction in head CT orders and increased use of ultrafast brain MR imaging.

First Report of Mexican papita viroid Infecting Greenhouse Tomato in Canada.

In the summer of 2008, tomato (Solanum lycopersicum) plants in a large greenhouse tomato facility located in Delta, British Columbia, Canada exhibited general stunting, chlorosis, and purple-leaf symptoms that were distinct from those of Pepino mosaic virus (PepMV) (1). Diseased plants were localized mainly in two rows in a section of the greenhouse and produced no fruits or only fruits with reduced size. Leaf samples were collected from four individuals among numerous diseased plants in this greenhouse. Screening samples by ELISA, PCR, or reverse transcription (RT)-PCR for PepMV, Tomato spotted wilt virus, Tomato yellow leaf curl virus, Tomato torrado virus, Tomato apex necrosis virus, and Begomovirus, Tobamovirus, and Pospiviroid species showed that all four plants had a mixed infection of both PepMV and a pospiviroid. RT-PCR with the pospiviroid-specific primers Pospil-RE and Pospil-FW (3) amplified the expected 196-bp products from these four samples. Each amplicon was cloned into the pCR4-TOPO vector (Invitrogen, Carlsbad, CA) and one individual cDNA clone from each isolate was sequenced. BLASTN analyses of nucleotide sequences of these clones showed 97 to 99% identity to Mexican papita viroid (MPVd) isolates currently in the NCBI Genbank. These four newly identified MPVd isolates were not identical; seven nucleotide substitutions or indels were identified in this region. The full viroid genome was obtained by RT-PCR in isolate VF2 with a new reverse primer MPVd-RE (5' GATCCCTGAAGCGCTCCT 3') in combination with the forward primer Pospil-FW (3). Using the same approach as stated above, this amplicon was cloned and sequenced. The nucleotide sequence of the 196-nt amplicon previously amplified and cloned from the isolate VF2 genome was identical to this region in the genomic clone. BLASTN analysis showed that the VF2 genome (GenBank Accession No. FJ824844) had >98% sequence identity to each of nine MPVd isolates (GenBank Accession Nos. L78454 and L78456-L78463), 94% identity to Tomato planta macho viroid (TPMVd) (GenBank Accession No. K00817) and ~80% identity to Tomato chlorotic dwarf viroid (GenBank Accession Nos. EF582392-EF582393). Prior to this find, MPVd had been identified only in papita (Solanum cardiophyllum) in Mexico and is considered a possible ancestor of TPMVd, Potato spindle tuber viroid (PSTVd), and possibly of other PSTVd-group viroids now infecting crop plants (2). The origin of MPVd in this greenhouse facility in Delta, British Columbia is unknown. The infected plants were destroyed by the grower. The pathogenicity of MPVd isolates characterized in this study was not evaluated on tomato because of quarantine regulations governing this viroid in the United States. The identification of MPVd infecting an important agricultural crop (tomato) outside its center of origin in Mexico indicates a potentially important major shift in the epidemiology of MPVd. To our knowledge this is the first report of MPVd from tomato in Canada. References: (1). K.-S. Ling et al. Plant Dis. 92:1683, 2008. (2) J. P. Martinez-Soriano et al. Proc. Natl. Acad. Sci. U.S.A. 93:9397, 1996. (3) J. Th. J. Verhoeven et al. Eur. J. Plant Pathol. 110:823, 2004.

Special care units: a typology of care settings for memory-impaired older adults.

After rating 55 nursing homes in five states, we created a typology of care settings that included eight distinct types of units designed to care for memory-impaired older adults. SCUs appeared to be associated with higher quality care than were traditional units, although quality of SCU care was not uniformly outstanding. This typology provides guidelines that can be used in preresidential analysis of prospective care units for demented older adults.

Exercise echocardiography in the detection of anthracycline cardiotoxicity.

Twenty long-term survivors of childhood cancer underwent exercise echocardiography to evaluate possible late anthracycline-induced cardiac toxicity. Ten patients ages 10 to 20 years had received anthracyclines, and ten patients ages 8 to 27 years had not received anthracyclines as part of their medical regimen. Both groups had normal cardiac function at rest. Patients who had not received anthracyclines had a greater increase in M-mode shortening fraction (P less than 0.005), velocity of circumferential fiber shortening (P = 0.05), and Doppler aortic peak flow velocity (P = 0.01) than patients receiving anthracyclines. There were no significant differences in work performed, or increase in heart rate or blood pressure with exercise between the groups. These results suggest that subtle abnormalities in myocardial function exist which become apparent only after exercise in survivors of childhood cancer who have received anthracyclines and have normal resting cardiac function.

Issues in cerebrospinal fluid management. Acid-fast bacillus smear and culture.

Meningeal tuberculosis is an uncommon disease in the United States with an annual incidence of fewer than 200 cases. This study evaluates three approaches to improving the use of the cerebrospinal (CSF) acid-fast bacillus (AFB) smear and culture procedure: (1) education alone; (2) optional screening by which physicians can select to have the AFB analysis stopped if the initial CSF findings are unremarkable; and (3) mandatory screening before the performance of all CSF AFB analyses. With education alone, the CSF AFB culture rate decreased from 20.6% of all CSF acquisitions to 15.7% (P less than 0.001); however, the effect may have been related to a decrease in all types of AFB testing. Optional screening had no impact on the AFB testing rate. Mandatory screening significantly decreased the CSF AFB rate to 6.7% (P less than 0.001), unrelated to changes in other types of AFB testing. Laboratories that employ mandatory screening should report the screening results immediately and have a mechanism whereby physicians can bypass the screen, providing CSF AFB analysis on unremarkable fluid from high-risk patients.

Management of cerebrospinal fluid.

In traditional practice, doctors order tests and the laboratory performs them. A series of tests are requested before the results of any of the tests are known. The authors of this paper examine the interface between the clinicians and the laboratory. They produce a cost effective and clinically useful routine for handling spinal fluid. They bring to their practice an excellent example of quality assurance which is genuine, improves practice and is not "busy work." The editor heard Dr. Albright present this material and urged him to make it available to North Carolina doctors.

CSF TRAP: a procedure to improve laboratory testing with myelography.

CSF TRAP (Transport and Rapid Accessioning for Additional Procedures) is a procedure that provides storage of and rapid access to cerebrospinal fluid (CSF) specimens and allows clinicians to review initial findings before ordering low-yield CSF studies. The cost-effectiveness of routinely using the CSF TRAP procedure with myelography is examined in a study group of 819 patients, 74% with disc diseases, spinal stenosis, spondylolisthesis, or pain syndromes, 10% with cancer, and 16% with neuropathies and miscellaneous conditions. Routine studies on CSF obtained during myelography provided little additional clinical information, except for patients with cancer (of 80 patients with cancer, the results of cytological examination of the CSF were positive in 12) and patients with multiple sclerosis, for whom oligoclonal band and IgG analysis provided supportive diagnostic data. The utilization of the CSF TRAP procedure with elimination of unnecessary culture and cytological studies on patients with disc diseases, spinal stenosis, spondylolisthesis, and pain syndromes, reduces myelographic CSF procedures by 20%, for a savings exceeding $14,000. The CSF TRAP procedure allows for a more cost-efficient analysis of CSF obtained using myelography, while providing fluid for analysis in patients with unexpected findings.

Amino acid sequences of helospectins, new members of the glucagon superfamily, found in Gila monster venom.

The amino acid sequences of two closely related peptides from Gila monster (Heloderma suspectum) venom are reported. Helospectin I is a 38-residue peptide, His-Ser-Asp-Ala-Thr-Phe-Thr-Ala-Glu-Tyr-Ser-Lys-Leu-Leu-Ala-Lys-Leu-Ala- Leu-Gln - Lys-Tyr-Leu-Glu-Ser-Ile-Leu-Gly-Ser-Ser-Thr-Ser-Pro-Arg-Pro-Pro-Ser-Ser, and helospectin II is a 37-residue peptide identical to helospectin I except that it lacks serine 38. Helospectins are pancreatic secretagogues with structures and bioactivities similar to vasoactive intestinal peptide and other members of the glucagon superfamily. The relative significance of helospectin-I and helospectin-II is presently unknown. Comparison of the 28 residues of vasoactive intestinal peptide with residues 1-28 of helospectin shows that identical amino acids occur in 15 positions. Since members of the glucagon superfamily have similar structures but different biological actions, it is possible that helospectin is more closely related to a mammalian peptide awaiting discovery.

Two complementary radiometric methods for the measurement of 5-amino-4-imidazole-N-succinocarboxamide ribonucleotide synthetase (SAICAR synthetase).

Two complementary methods have been devised for measuring the activity of 5-amino-4-imidazole-N-succinocarboxamide ribonucleotide synthetase (SAICAR synthetase, EC 6.3.2.6), a critical enzyme in the pathway of purine biosynthesis. In the first method, L-[4-14C]aspartic acid is condensed with 5-amino-4-imidazolecarboxylic acid ribonucleotide (AICOR) via the action of SAICAR synthetase. Unreacted L-[4-14C]aspartic acid is quantitatively dissipated by enzymatic decarboxylation, and the residual radioactivity is measured by scintillation spectrometry. In the second method, the reverse reaction of SAICAR synthetase is measured; radioactive 5-amino-4-imidazole-N-succinocarboxamide ribonucleotide (SAICAR) is synthesized enzymatically, using a partially purified preparation of SAICAR synthetase from chicken liver. To the purified [14C]SAICAR is added: sodium arsenate, Tris-HCl buffer containing ADP--MgCl2 or buffer alone, and to initiate the reaction, a 12 000 x g supernatant or other suitable source of enzyme. As a consequence of the arsenolytic cleavage of [14C]SAICAR, L-[4-14C]aspartic acid is generated in stoichiometric amounts. The fourth carbon of this amino acid is then detached by selective enzymatic decarboxylation, trapped in 40% KOH and quantitated by scintillation spectrometry. The assays, performed as prescribed, are facile and notably sensitive; using them, the specific activity of SAICAR synthetase has been measured in acetone powders of the livers of representative members of Vertebrata, and also in the principal viscera of the mouse. Of the livers examined, pigeon liver was the richest source of the investigated enzyme.